Healthcare Provider Details

I. General information

NPI: 1972772655
Provider Name (Legal Business Name): BAMBI L NICKELBERRY MD PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 N LOCUST ST
INGLEWOOD CA
90301-1258
US

IV. Provider business mailing address

248 N LOCUST ST
INGLEWOOD CA
90301-1258
US

V. Phone/Fax

Practice location:
  • Phone: 310-673-3737
  • Fax: 310-673-0248
Mailing address:
  • Phone: 310-673-3737
  • Fax: 310-673-0248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG466791
License Number StateCA

VIII. Authorized Official

Name: DR. BAMBI LYNN NICKELBERRY
Title or Position: DIRECTOR/OWNER
Credential: M.D.
Phone: 310-673-3737